The Nursing Head-to-Toe Assessment

Introduction

A nursing assessment is a primary step in diagnosing and treating a condition. If the assessment is performed correctly, it can assist in establishing differential diagnoses, determining a plan of care, and ordering further testing. The present paper details a primary assessment of a 58-year-old male who complains about abdominal pain and constipation.

Patient Body Systems Assessment

It is expected that the assessment will produce no abnormal findings besides tenderness in the abdominal area, which may be due to constipation. Any swelling, redness, tenderness, or functional disruption would indicate abnormal findings.

Vital Signs

Heart rate is 103 BPM (normal 60-100 BPM).

Body temperature is 36.5°C (normal 36°C).

Blood pressure is 160/92 mm Hg (normal blood pressure for patient’s gender and age is approximately 130/85).

Respiratory rate is 23 breaths/min (normal 16 – 20).

Consciousness and Orientation

The patient is alert and oriented, actively reacts to questions.

Skin

The skin on the patient’s arms appears red and swollen. The patient clarifies that got sunburn after spending the day in the sun yesterday.

HEENT

The scalp is in healthy condition. Pupils, conjunctiva, and sclera are in normal condition. The nasal mucosa is normal. External auditory canals are in normal condition. The tympanic membrane is functioning normally. No redness, swelling, or exudate in the oral pharynx. Gums and teeth are in good condition. The tongue appears to be lightly coated.

Neck

The neck is movable, non-tender. The thyroid gland is palpable, with no signs of abnormalities. JVP is 10 cm at 45 degrees.

Chest

Lungs appear to be clear, no abnormal sounds detected. Heartbeat clear.

Abdomen

The patient’s abdomen is symmetrical, with tenderness in the naval area. Minimal bowel sounds discerned. Liver span is normal at 11 cm.

Extremities

Extremities appear normal, with no signs of redness or swelling. Peripheral pulse can be palpated in all areas and within the normal range.

Nodes

No enlarged or inflamed nodes were detected during the palpation.

Rectal and Genital Inspection

No stool available for inspection. The patient reports that stool is of normal color, with no blood, and formed. No pathological changes to the genitals.

Neurology

Neurological examination revealed no abnormalities. Cerebellar and gait functions are regular. Reflexes are normal on both sides; cranial nerves are in normal condition.

Differential Diagnosis

Constipation is the most probable diagnosis. Constipation is often caused by unhealthy eating habits and the lack of fiber in the diet. The patient appears to be obese and admits to having poor eating habits, which is a major risk factor for constipation. Nevertheless, there is also a possibility that the patient’s symptoms are caused by colon cancer. Risk factors for colon cancer that are evident in the patient include high body mass index, low rate of physical activity, and poor diet (Johnson et al., 2013). The recommended diagnostic test to rule out colon cancer is colorectal cancer screening. According to the American Cancer Society (2018), a guaiac-based fecal occult blood test (gFOBT) would help to rule out cancer. Normal laboratory findings for a gFOBT would indicate a negative result, with no blood found in the feces (Geraghty et al., 2014). If the results are unclear or weakly positive, a colonoscopy will be required to determine the presence of colon cancer.

Age-Specific Risk Reduction, Health Screen, and Immunizations

Given the patient’s age, gender, and present condition, the patient is at risk for heart disease, diabetes, and cancer. Therefore, age-specific risk reduction strategies should include a low-carbohydrate diet and regular exercise. A low-carbohydrate diet would reduce the patient’s risk for diabetes and heart disease, while regular exercise would help to promote cardiovascular health (Malhotra, Noakes, & Phinney, 2015).

Monitoring of blood pressure, blood glucose, and cholesterol is also required to track the patient’s health status. In addition, the patient should complete regular cancer screenings, as his age and gender put him at increased risk for colorectal cancer and prostate cancer. Regular flu immunizations would help to prevent influenza and the complications that may be associated with it.

Plan of Care

Nursing Diagnosis

The actual nursing diagnosis for the patient is constipation. This is evidenced by the patient’s complaints, as well as by the physical assessment of the patient. However, the patient is also at risk for colon cancer and would require further diagnostic tests to confirm or refute this suggestion. Lastly, the patient shows readiness for improving wellness, particularly in terms of dietary changes. The patient appears to be motivated to avoid the risk of cardiovascular disease and diabetes, which is why he is interested in making changes to his diet. The patient states that he would also consider improving his activity levels by adding light exercise.

Interventions

The key intervention to address both the actual diagnosis and the risk factors for other diseases is a low-carb diet. This is an evidence-based health promotion practice, as a low-carb diet proved to be effective in reducing body mass, blood glucose, and cholesterol, thus promoting cardiovascular health and preventing diabetes (Bazzano et al., 2014). In addition to a low-carb diet, the patient should consume a recommended amount of dietary fiber and water daily. The assessment also showed a high heart rate and increased blood pressure, which may be a sign of hypertension. Medication treatment for the patient should include beta-blockers, such as Levatol, taken at 20 mg daily.

Evaluation

Evaluation of the patient’s condition should be performed in one month. It should include a full physical assessment and a discussion of complaints, as well as a review of laboratory findings. If the treatment is effective, the patient should indicate a regular bowel movement, decreased body weight, and improved overall wellness.

Evidence-Based Health Promotion

First of all, the paper recommends a gFOBT in order to rule out cancer. A gFOBT is recommended by the guideline of the American Cancer Society (2018) as one of the critical tests in diagnosing colorectal cancer. Another essential recommendation provided here is a low-carb diet. This recommendation is supported by multiple randomized trials, including the study by Bazzano et al. (2014), which found a low-carb diet to be more effective than a traditional low-fat diet in reducing blood glucose and body mass, as well as in improving other wellness indicators. Therefore, following a low-carb diet would help to improve the patient’s health and reduce his risk for heart disease and diabetes.

Lastly, the paper recommends using Levatol for reducing blood pressure and heart rate to average values. This provision is supported by the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults (James et al., 2014). Recommendation 3 of the guideline states that “In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg” (James et al., 2014, p. 511). Levatol is a beta-blocker that is used to treat mild and moderate hypertension. A standard dose of 20 mg daily should be effective in reducing the patient’s blood pressure and heart rate to normal.

Conclusion

Overall, the head-to-toe assessment of the patient indicated certain problems that will require further diagnostics, as well as treatment. The assessment enabled the nurse to suggest that the patient has constipation and is at risk of colon cancer. However, the evidence-based recommendations provided in the paper will assist in improving the patient’s condition and improving his wellness.

References

American Cancer Society. (2018). Web.

Bazzano, L. A., Hu, T., Reynolds, K., Yao, L., Bunol, C., Liu, Y.,… He, J. (2014). Effects of low-carbohydrate and low-fat diets: A randomized trial. Annals of Internal Medicine, 161(5), 309-318.

Geraghty, J., Butler, P., Seaman, H., Snowball, J., Sarkar, S., Blanks, R.,… Rees, C. J. (2014). Optimising faecal occult blood screening: Retrospective analysis of NHS bowel cancer screening data to improve the screening algorithm. British Journal of Cancer, 111(11), 2156-2162.

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J.,… Smith, S. C. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520.

Johnson, C. M., Wei, C., Ensor, J. E., Smolenski, D. J., Amos, C. I., Levin, B., & Berry, D. A. (2013). Meta-analyses of colorectal cancer risk factors. Cancer Causes & Control, 24(6), 1207-1222.

Malhotra, A., Noakes, T., & Phinney, S. (2015). British Journal of Sports Medicine. Web.

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